Integrated Care Management (ICM) and medicines management

1. Integrated Care Management (ICM) and medicines management Catherine Leon, 2012

2. Objectives This slide pack covers: • Why older people are at a higher risk of medicines related problems • The factors that contribute to this problem • The physical, behavioural and environmental factors have an impact on how they use their medicines • The warning signs that an older person may be at risk of a medicine related problem • WHEN, HOW and WHERE to refer patients for further medicines support

3. Structure • Older people and medicines issues • The role of ICM in medicines optimisation • Practicalities

4. Medicines in Long Term Conditions (LTC) • Prescribing is the most common intervention in the NHS1 • Between half and a third of all medicines for LTC are not taken as recommended2 • Improving medicines taking may have a greater impact on clinical outcomes than an improvement in treatments3 • NHS Information Service • Horne R et al 2005. Concordance, adherence and compliance in medicine-taking. Report for the national co-ordinating • centre for NHS service delivery and organisation R&D • Cochrane Database Syst Rev 2008

5. Older People and Medicines Older People are at greater risk of having a medicine related problem Over 60’s are 3 times more likely to have a drug related hospital admission v under 30’s Take more medicines Have higher risk of adverse drug effects Consequences of adverse effects may be more severe

6. Older people take more medicines (polypharmacy) • Over 65 years account for more than 50% of NHS prescriptions • 1 in 3 over 75 take more than 4 medicines • With age, more diseases leading to • Multiple prescribers and pharmacies (hospital, outpatients, GP surgeries) • Target driven overprescribing

7. Older people have greater risk of adverse drug reactions • Age related changes affect how medicines work in the body • Mental and physical function decline • Swallowing difficulties • Reduced dexterity and limb weakness • Visual loss (80% have visual impairment) • Hearing impairment • Reduced mobility • Forgetfulness • Falls • Poor nutrition • Adherence issues • Social issues (e.g. isolation, language, literacy)

8. The burden of adverse drug reactions (ADR) • Projected cost to the NHS is £466 million per annum • Responsible for around 5-17% of hospital admissions • More than 2% of patients admitted with an ADR died • 72% of ADRs were definitely or possibly avoidable • Many remain undiagnosed • Most common are: falls, GI, haematological, delerium and anticholinergic side effects DOH 2005, Smith et al, 1996; Bandolier, 2002; Pirmohamed et al, 2004

9. OP more likely to be at risk from ADRs Number of active chronic medical diagnoses (> 6) >6 medications or > 12 doses per day Recent transfer to or from hospital (acute episode or exacerbation of LTC) Complex drug regimens Advanced age (> 75 years) & increasing frailty Prior adverse drug reaction Cognitive impairment including dementia Cancer, Depression Decreased renal function Extreme body weight or BMI • 9

10. Red flag drugs • Commonly associated with ADRs: • Warfarin • Insulin • NSAIDs • Diuretics • Digoxin • Antipsychotics • Anticholinergics • Benzodiazepines • Opioid analgesics

11. Non adherence • Can lead to poor outcomes • Influenced by multiple factors • 2 main reasons • Intentional (can and wont) • non intentional (can’t) • Overlap • Important to determine reason for non adherence as this can influence solution

12. Role of ICM in medicines optimisation

13. Medicines and the Integrated Care Programme • Criteria for being included on the Integrated Care Programme register • Criteria #7: “Is the person on four or more medications including one of six medicines with the highest risk of hospital admission (insulin, warfarin, NSAIDs, digoxin, diuretics and antipsychotics)?” • Holistic Health Assessment • Has patient had a medicine review within the last year?

14. ICM medicines tool

15. ICM will need to find out:

16. If yes to any of above: Refer to community pharmacist

17. Community pharmacy options for supporting medicine taking • Large font labels for poor eyesight • Alternative packaging if difficulty removing tablets from blisters (e.g. large bottles with non clic-lock lids) • Devices to aid eye drop or inhaler or cream delivery • Repeat collection and dispensing service • Delivery service (not compulsory, unfunded) • Compliance devices • Medicines Use Review • Liaison with GP regarding formulations • Medicine information

18. Medicine Use Review (MUR) • Not a medication review, only can be done by Community Pharmacist • Helping patients understand their therapy • Identify any problems with using medicines • Jointly find solutions that work for them • Free service • “Medicine Check-up” • Targeted MURs

19. Case Management Pharmacist • Case Management Pharmacist • Available to contact for advice • For referrals of patients with complex medicine issues via community matrons • Specialist advice and attendance at CMDT when required for patients with complex medicines management issues • Catherine Leon • catherine.leon@gstt.nhs.uk • 07557 499 540

20. Other contacts for Medicines advice • Community pharmacist • Contact details on the dispensing labels • First contact for general queries and advice • NHS direct – 0845 46 47 • GSTT Pharmacy department (24 hours, on call service) • Medicines helpline for medicines related to recent admissions: 020 7188 8748 (GSTT & Kings College Hospital)